How to Bill for an Interim Physician: A Comprehensive Guide
This article provides a concise answer to How Do I Bill for an Interim Physician?: Interim physician billing depends largely on the contractual agreement – whether the physician is operating as a W-2 employee of your facility, an independent contractor, or is provided through a staffing agency, each requiring a distinct approach to compliant and accurate medical billing.
Understanding Interim Physician Billing
Interim physicians, sometimes called locum tenens physicians, fill temporary staffing gaps in healthcare facilities. Billing for their services can be complex and requires careful attention to detail to ensure compliance with regulations and accurate reimbursement. The specific billing process depends heavily on the employment arrangement. This article aims to demystify the process.
Benefits of Using Interim Physicians
Interim physicians offer several key advantages:
- Continuity of Care: They prevent disruptions in patient care when a permanent physician is unavailable.
- Revenue Generation: They allow facilities to maintain service levels and revenue streams.
- Flexibility: They provide a flexible staffing solution to meet fluctuating patient demand.
- Evaluation Period: They can serve as a trial period for potential permanent hires.
- Specialized Skills: They can bring specialized expertise to a facility on a temporary basis.
Key Factors Influencing Billing
Several factors influence how you bill for an interim physician:
- Employment Status: Is the physician a W-2 employee, an independent contractor, or provided by an agency?
- Credentialing: Is the physician properly credentialed and privileged at your facility?
- Payer Rules: What are the specific billing rules of Medicare, Medicaid, and private insurers?
- “Incident To” Services: Can the interim physician’s services be billed “incident to” a permanent physician?
- Place of Service Codes: Are the correct place of service codes being used?
Billing Process: Step-by-Step
While the details vary, here’s a general outline of the billing process:
- Determine Employment Status: Clearly define the legal relationship with the interim physician.
- Credentialing and Privileging: Ensure the physician is properly credentialed and privileged at your facility before they begin seeing patients.
- Documentation: Maintain accurate and complete documentation of all services provided by the interim physician.
- Coding: Assign the appropriate CPT and ICD-10 codes to each service.
- Claim Submission: Submit claims to payers according to their specific requirements.
- Payment Posting: Post payments accurately and reconcile accounts.
- Denial Management: Address any claim denials promptly and effectively.
Common Billing Mistakes
Avoid these common pitfalls to ensure accurate reimbursement:
- Incorrect Employment Status: Misclassifying the physician’s employment status can lead to tax and legal issues.
- Lack of Credentialing: Billing for services provided by an uncredentialed physician can result in claim denials and potential fraud allegations.
- Inadequate Documentation: Insufficient documentation can support medical necessity and lead to claim denials.
- Incorrect Coding: Using incorrect CPT or ICD-10 codes can result in overpayments or underpayments.
- Failure to Follow Payer Rules: Ignoring payer-specific billing guidelines can lead to claim denials.
Three Main Billing Models
The method you use to bill for an interim physician is largely determined by their relationship to your facility:
- Agency/Staffing Company Model: The staffing agency is the employer. The agency bills the facility for the physician’s services, and the agency pays the physician. The facility does not directly bill payers for the services.
- Independent Contractor Model: The physician is a self-employed individual. The physician bills the facility directly for their time. The facility then bills the payers for the services the physician provides, using the facility’s NPI.
- W-2 Employee Model: The facility employs the physician. In this case, the facility will bill the payers for the physician’s services just as they would for a permanent employee.
Sample Billing Table
| Employment Model | Who Employs the Physician | Who Bills the Facility? | Who Bills the Payers? |
|---|---|---|---|
| Agency | Staffing Agency | Staffing Agency | Facility (on behalf of the agency physician) |
| Independent | Physician | Physician | Facility |
| W-2 | Facility | N/A | Facility |
“Incident To” Billing Considerations
“Incident to” billing allows certain services provided by non-physician practitioners (NPPs) to be billed under the supervising physician’s National Provider Identifier (NPI) if specific requirements are met. Generally, services provided by an interim physician cannot be billed “incident to” a permanent physician because they are not considered NPPs working under the direct supervision in a defined ongoing care context.
Understanding Modifiers
Specific modifiers may be necessary when billing for locum tenens physicians, depending on the payer and the circumstances. The Q6 modifier is often used on Medicare claims to indicate that services were provided by a substitute physician. Understanding and utilizing these modifiers correctly is critical for proper reimbursement.
Keeping Updated on Policy Changes
Regulations surrounding interim physician billing are subject to change. Regularly consult with billing experts, legal counsel, and relevant professional organizations to stay informed about the latest updates and ensure compliance.
Frequently Asked Questions
Can I bill for an interim physician if they don’t yet have privileges at my facility?
No, you generally cannot bill for an interim physician if they do not have the proper credentials and privileges at your facility. Billing for services provided by an uncredentialed physician can lead to claim denials and potential legal repercussions. The physician must be fully credentialed before they start providing services.
What documentation is required to support claims for services provided by an interim physician?
The documentation requirements are generally the same as for permanent physicians. This includes detailed notes outlining the patient’s history, physical exam findings, diagnosis, treatment plan, and progress. Be sure that the documentation is complete, accurate, and legible.
How does the ‘Q6’ modifier work when billing for an interim physician under Medicare?
The Q6 modifier is a Medicare-specific modifier that indicates that services were provided by a substitute physician during a regular physician’s absence. To use the Q6 modifier, the regular physician must be absent for reasons such as illness, vacation, or continuing medical education, and the interim physician must meet certain requirements. This allows the interim physician’s services to be billed under the absent physician’s NPI.
If I use an interim physician through an agency, do I need to handle the billing myself?
Typically, if you use an interim physician through an agency, the agency handles the billing. You pay the agency for the physician’s services, and the agency is responsible for paying the physician. You will likely not be billing the payers directly for the physician’s services in this scenario. Review your contract with the agency carefully.
What is the best way to ensure that I am following all applicable billing rules?
The best way to ensure compliance is to stay informed about the latest billing regulations and guidelines. Consult with billing experts, legal counsel, and relevant professional organizations. Consider implementing a robust compliance program that includes regular audits and training for your staff.
What are the tax implications of using an interim physician as an independent contractor versus a W-2 employee?
The tax implications differ significantly. As an independent contractor, the physician is responsible for paying their own self-employment taxes. As a W-2 employee, you are responsible for withholding and paying employment taxes, such as Social Security, Medicare, and unemployment taxes. Misclassifying the physician’s employment status can lead to significant tax penalties.
How do I determine the appropriate CPT codes for services provided by an interim physician?
The process is the same as determining CPT codes for any other physician. Review the documentation of the services provided and select the codes that most accurately reflect the work performed. Consult with coding experts if you have any questions.
What happens if a claim for services provided by an interim physician is denied?
If a claim is denied, review the denial reason carefully. Determine whether the denial was due to an error in the claim, insufficient documentation, or some other issue. Correct the error, gather any necessary additional documentation, and resubmit the claim.
Is there a limit to how long I can use the Q6 modifier for an interim physician covering for a permanent physician?
Medicare has limits on the duration for which you can use the Q6 modifier for a specific physician absence. Generally, the substitution arrangement cannot exceed 60 days. Refer to the latest Medicare guidelines for specific details.
Can an interim physician order durable medical equipment (DME) for Medicare patients?
Yes, an interim physician can generally order DME for Medicare patients as long as they are enrolled in Medicare and have the legal authority to order such equipment in the state where they are practicing. Ensure that the DME orders meet all Medicare requirements.
What is the best way to track the hours worked by an interim physician for billing purposes?
Accurate tracking of hours is essential for proper billing. Implement a system to record the physician’s start and end times for each shift. This could involve time sheets, electronic time clocks, or other methods. Verify the hours worked with the physician regularly to ensure accuracy.
How does the type of insurance (Medicare, Medicaid, commercial) affect how I bill for an interim physician?
Each payer has specific billing requirements and guidelines. Medicare, Medicaid, and commercial insurers may have different rules regarding credentialing, documentation, coding, and modifier usage. Review the specific rules for each payer before submitting claims.